Provider Demographics
NPI:1043388465
Name:FLAGG, JEFFERY S (DDS, MD)
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:S
Last Name:FLAGG
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18600 GOLF LN
Mailing Address - Street 2:
Mailing Address - City:HAZEL CREST
Mailing Address - State:IL
Mailing Address - Zip Code:60429
Mailing Address - Country:US
Mailing Address - Phone:708-922-1108
Mailing Address - Fax:708-922-1236
Practice Address - Street 1:1820 RIDGE RD STE 301
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-1759
Practice Address - Country:US
Practice Address - Phone:708-922-1108
Practice Address - Fax:708-922-1236
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL21623278OtherBCBS
IL21623278OtherBCBS